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Global TB response under pressure from threat of drug resistance

Report finds proven tools and techniques to stop the disease are under-utilised

Only 5% of patients suffering with Drug Resistant-TB have access to the new drugs – bedaquiline and delamanid – which can offer them hope of a cure. This stark statistic is highlighted in a new report from Médecins Sans Frontières (MSF), in collaboration with the Stop TB Partnership, which examines and evaluates the tuberculosis (TB) policies of 29 respective countries, which together comprise approximately 82% of the global ‘TB population’.

Its timely release precedes a series of major international conferences where the fight against TB will be high on the agenda, most notably the WHO ‘Global Ministerial Conference on Ending TB in the Sustainable Development Era’ (Moscow, November 2017), the UN High-Level Meeting on TB (New York, September 2018) and the 2018 G20 Summit (Buenos Aires).

Despite the fact that the disease is preventable and can be treated, the ‘Out of Step 2017’ report shows that many countries have in fact failed to effectively utilize ‘new tools’ that are available in the fight against TB. Without the implementation of new policies that take advantage of these developments, TB will remain the world’s deadliest infectious disease. Whilst 6.1 million people were diagnosed with TB in 2015, a further 4.3 million people are estimated to have the acquired the disease in the same year. The less accurate that TB detection methods are, and the longer they take, the less likely it is that affected individuals will receive the treatment they need; unfortunately, that also means that they are less likely to survive. In 2015, 1.8 million people died from the disease. Currently, a person dies of TB every 18 seconds.

The report urges the acceleration of new treatments. Although delamanid and bedaquiline – medicines – usually recommended for those with ‘few or no treatment options – feature in 62% (delamanid) and 79% (bedaquiline) of national guidelines, approximately only 5% of those with DR-TB have access to these medicines. Despite the availability of new treatments, only 75% have implemented “accelerated registered mechanisms.” Furthermore, of the 41% of countries who are enrolled in the WHO ‘Collaborative Registration Procedure’, none have listed all of the WHO-recommended anti-TB medicines (for the treatment of DR TB) in their national Essential Medicines List (EML).

More broadly, inaction, conservatism and outdated policies and practices amongst the 29 countries are identified by the report as the key ‘barriers’ to addressing the global TB problem. Although the report recognises the importance of the World Health Organization’s (WHO) ‘End TB Strategy’ in the fight against TB, it also notes that a number of countries have not adopted its policies and guidelines, which are ‘proven to reduce TB incidence and death.’ Of those who have adopted the guidelines, many have failed – or have simply taken too long – at the implementation stage.

Xpert MTB/RIF, ‘a rapid molecular test that can diagnose TB and detect rifampicin resistance (RR) in 2 hours’, is identified within the report as the first step in addressing the ‘diagnostic gap’. Whilst 52% of the 29 countries have adopted an ‘Xpert for all’ policy, just 47% of these have ‘widely implemented’ this approach. Of the 7 countries to make Xpert MTB/RIF widely available, however, none were from the Asia-Pacific region. Furthermore, Universal Drug-Sensitivity Testing (DST) – which should particularly be available for RR TB patients – is recommended by 62% of the countries, yet has been widely implemented by just half of those countries. Without the full implementation of these recommended tests, it is difficult to imagine that the diagnostic gap will begin to close.

Moreover, the survey found that in 24 of the countries, Drug-Sensitive (DS) TB is ‘started at the primary health care level’, with 20 of these 24 nations having implemented the program widely. Of the 19 countries who initiate treatment for DS TB at the district level, however, just 11 do so widely. These figures, along with the finding that 34% of the countries require hospitalization for almost all patients, leads the report’s authors to declare that “the decentralization of patient-centered care must significantly accelerate if countries are to seriously improve treatment outcomes for people diagnosed with TB.”

Although there are numerous findings that are revealed in the report, the core assertion made is that more can be done to reduce the severity of TB as the world’s deadliest disease. The figure of 1.8 million TB deaths in 2015, it is argued, would be much smaller if a multi-sector national and international approach was utilised as a means of implementing the most up-to-date practices for TB prevention, diagnosis and treatment. Countries must prioritise TB within their respective national health policies/systems, and as such must “revamp their drug regulatory pathways, adjust their procurement processes, update their TB guidelines and policies, accelerate full implementation of these policies, and ensure health budgets are matched to health needs.”

The WHO ‘Global Ministerial Conference on Ending TB in the Sustainable Development Era: A Multisectoral Response’, to be held in Moscow next month, will also assert the notion that ‘more could be done’ to address the global TB problem. Indeed, its central aim will be to “accelerate implementation of the WHO End TB Strategy”, so that the Sustainable Development Goal 3 target to ‘end the epidemic of TB’ by 2030 can be met. MSF is urging all stakeholders to use the coming year of global mobilisation around TB – culminating in the UN High Level Meeting on TB in September 2018 to heed the messages from ‘Out of Step’ and through that, accelerate progress towards the elimination of the world’s deadliest disease.

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